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Occupational Medicine 2012;62:242–253 doi:10.1093/occmed/kqs051 IN-DEPTH REVIEW HIV and employment C. McGoldrick Department of Infectious Diseases, Monklands Hospital, Airdrie ML6 0JS, UK. Correspondence to: C. McGoldrick, Department of Infectious Diseases, Monklands Hospital, Airdrie ML6 0JS, UK. e-mail: [email protected] Abstract According to 2009 statistics, the human immunodeficiency virus (HIV) infected an estimated 86 500 individuals within the UK, although around one-quarter were unaware of their infection. In the majority of cases, it is now considered a long-term controllable but incurable infection. Indeed, most HIV-positive individuals are able to work. Employment is across most, if not all, workforce sectors and protection against workplace discrimination is provided by the Equality Act 2010. Issues including confidentiality, workplace adjustments, vaccinations and travel restrictions may be relevant to the occupational health of HIV-positive workers. There are special considerations concerning HIV-infected health care workers, including avoidance of performing exposure-prone procedures. Prevention of HIV acquisition in the workplace is relevant to a diverse range of occupational environments, and HIV post-exposure prophylaxis should be considered after potential HIV exposure incidents. If a worker contracts HIV by occupational means, financial help may be available. Key words Employment; HIV; occupational health; occupational medicine. Introduction Literature search An estimated 86 500 people in the UK are infected with human immunodeficiency virus (HIV), with around one-quarter unaware of their infection [1]. Since the initial recognition of the acquired immunodeficiency syndrome (AIDS) in 1981, a major shift in HIV’s prognosis has been observed. Whereas in the past it was considered almost universally fatal with increasing time since infection, due to the success of highly active antiretroviral therapy (HAART), it is now considered a long-term controllable condition in the majority of individuals [2–4]. Currently licensed antiretroviral drugs function by decreasing effective viral replication, viral entry into cells or integration with the host cell genome. In doing so, plasma viral loads reduce, further decreasing the amount of virus that can invade and destroy CD4 T cells [5,6]. CD4 count rises and/or further prevention of CD4 decline results, thereby decreasing the risk of opportunistic and other HIV-associated illness. Consequently, many people who would otherwise have become too unwell to work can remain in employment or re-enter the job market [7]. This review will primarily focus on current UK policy and thinking concerning HIV infection in relation to employment, although some examples from other countries will be given. It will cover issues relating to the employment of HIV-positive individuals and prevention of occupational exposure and acquisition of HIV. A search was conducted of guideline and publication lists embedded within various UK governmental and nongovernmental websites for documents relevant to the topic of ‘HIV and employment’. Websites searched were those of the British HIV Association; the UK Expert Advisory Group on AIDS (EAGA); the UK Department of Health; the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP); the Health Protection Agency; Health Protection Scotland; Department of Health, Social Services and Public Safety, Northern Ireland; the National Public Health Service for Wales; the National AIDS Trust; the UK Ministry of Defence; the UK Civil Aviation Authority (CAA); Her Majesty’s Prison Service; the Scottish Prison Service; and the Organization of the Petroleum Exporting Countries. Relevant documents were identified in this manner. An additional Pubmed search was made using the search terms ‘HIV AND employment’ and setting limits of ‘English language’, ‘Humans’ and publication within 10 years. Of the 691 Pubmed references generated, only those considered to be relevant both to the subject and to UK policy were considered for inclusion. Articles relating to prostitution and those within patient advocacy journals were excluded. The review was formed by drawing on information obtained from the above searches, as well as from a personal collection of documents/articles/ resources, and from papers identified from the reference © The Author 2012. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected] C. McGOLDRICK: HIV AND EMPLOYMENT 243 lists of such articles. Although it provides an overview of many employment issues pertaining to HIV infection, it cannot be fully comprehensive. The reader is therefore directed to the relevant UK policy/guidance documents for further information where required. medication scheduling and concerns about how health will affect their work [21]. Medication reminders aiding antiretroviral adherence, e.g. alarms set on mobile phones, may be particularly helpful for those with erratic shift patterns. HIV and employment in general Recruitment of HIV-positive workers Roles in the workforce Although questions that would lead to HIV disclosure may be asked within pre-employment health questionnaires, this should not affect recruitment except in some circumstances. These include where the illness is severe enough to affect work performance, and there are also some recruitment restrictions for the armed forces, airline pilots and air traffic controllers [22–25]. In addition, health care workers (HCWs) have been restricted from roles involving exposure-prone procedures (EPPs) (see Box 1) although there is currently a consultation ongoing regarding changing these regulations [26–28]. HIV status should not be disclosed by occupational health departments, without the employee’s express consent, consistent with General Medical Council (GMC) guidance on confidentiality [29]. However, they may advise if a change of duties is required [26,27]. An infected worker’s identity may, however, be disclosed, where necessary to prevent the spread of infection, but this must be justifiable [26,27,30,31]. Employment of individuals with HIV occurs across all employment sectors. In one survey undertaken in 2009 within a large HIV clinic, 74% (401/545) were in some kind of work, 51% were in full-time paid employment, 9% in full-time self-employment, 4% in part-time paid employment, 5% in part-time self-employment, 3% in training and 1% looked after family dependants [8]. In another survey, conducted by the National AIDS Trust, utilizing Gaydar (a large social networking site for men who have sex with men (MSM)), 84% (n = 1830) of HIV-positive MSM were in stable permanent employment. Employment sectors included hospitality (10%), health care/medicine (9%), retail (7%), education (7%), information technology (6%) and financial services (6%). About 58% felt that HIV had no adverse effect on their working life [9]. Indeed, employment itself may be therapeutic, allowing improved self-esteem, self- fulfilment, better social networks, lower fatigue levels and an overall better quality of life [10–14]. Factors limiting ability to work Factors that may limit ability to work include HIVassociated neuropsychological impairments (e.g. problems in executive functioning and memory), psychosocial problems, depression, medical factors such as fatigue and illness related to opportunistic/other illnesses and side-effects of antiretrovirals (e.g. potentially reversible efavirenz-related dizziness) [13,15–19]. However, in the initial survey described previously, 83% (333/401) of HIV-positive people in work perceived no barriers to remaining in employment [8]. Another study of HIV-positive people (n = 1627) in London undertaken between June 2004 and June 2005 found unemployment to be significantly associated with time since HIV diagnosis (adjusted odds ratio (aOR) = 1.13 per year, 95% confidence interval (CI) = 1.07–1.19), previous hospital admission for HIV-related symptoms (aOR = 1.94, 95% CI = 1.17– 3.21), visible physical signs of HIV (aOR = 2.01, 95% CI = 1.21–3.33), detectable viral load (aOR = 2.10, 95% CI = 1.06–3.79) and lower education (aOR = 3.85, 95% CI = 2.27–6.25) [20]. Employment concerns of HIV-positive individuals Employment concerns felt by HIV-infected individuals include fear of discrimination/stigma, concerns regarding Discrimination against HIV-infected workers In the previously mentioned National AIDS Trust survey using Gaydar, 62% had disclosed their diagnosis to someone at work, contrasting with a survey of London clinic attendees where only 37% had disclosed [8,9]. In the latter study, although stigma and fear of discrimination were of concern for almost half of individuals, only 11% of those in work reported actually experiencing it, indicating that the problem may not be as great in reality as perceived [8]. The situation can differ in other countries. China’s national policy for recruiting civil servants specifies that Box 1. Definition of exposure-prone procedures (EPPs) Exposure-prone procedures are invasive procedures where there is a risk that a w orker’s blood, in circumstances of injury, may contaminate a patient’s open tissues (bleed-back). E xamples include those where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. bone spicules or teeth) inside a patient’s open body cavity, wound or confined anatomical space where hands or fingertips may not always be completely visible. 244 OCCUPATIONAL MEDICINE individuals with HIV will be disqualified. Additionally, similar exclusions apply to the Chinese police force and working in bars, hotels, restaurants, beauty parlours and hairdressing salons, although this contravenes their Employment Promotion Law (2007) [32]. Closer to home, a French study reported workplace discrimination to be associated with increased risk of employment loss among those who had achieved only a primary/secondary educational level but not among those further educated. Risk of job loss was lower among those holding managerial or executive positions compared with other occupational positions [33]. In October 2010, the Equality Act 2010 came into force and replaced various acts including much of the Disability Discrimination Act [25,34]. For the purposes of the act, HIV is considered a disability and is covered by it from the point of diagnosis. The act legally protects people with disabilities from discrimination, providing rights in respect of various aspects of life including employment [25–27,34]. Workplace discrimination because of infection is therefore unlawful, as is denial of employment related to HIV status, unless the employer has justification based on a material and substantial reason [25,34]. As before, an example would be an HCW undertaking/potentially undertaking EPPs, although this is under review [26–28]. Workplace adjustments for individuals living with HIV The act also provides a duty on the part of the employer to consider what workplace adjustments within an employee’s role are reasonable [27,34]. Such adjustments include (where available) moving an HCW to a post where EPPs can be avoided. Medical and occupational health supervision should, however, continue [27,30,31]. In the previously mentioned National AIDS Trust study of HIV-positive MSM, 89% of requests for reasonable adjustments were granted, including time off for clinic attendance in 67% of requests. About 34% of HIV-positive respondents had not taken any time off for clinic attendance during the preceding 12 months, 46% used existing flexibility within working arrangements and 9% used annual leave to attend clinics [9]. Individuals with HIV commonly attend clinic every 3 months, sometimes less frequently when the disease is stable. It may, however, be more frequent at certain times, e.g. early after diagnosis, around the time of antiretroviral initiation, or during periods of disease instability or p rogression [9]. Some workplace adjustments may be necessary to allow a worker to take antiretroviral medication at the correct times, as delayed therapy may encourage antiretroviral resistance. Simpler regimens are now available, although they will not be suitable for everyone. They are simpler in terms of administration frequency and lack of need for refrigeration. Not all HIV-positive workers will require antiretroviral therapy, with current UK guidance suggesting, with exceptions, that it be considered when CD4 count is below 350 cells/mm3 [35]. However, guidance may change in future to higher CD4 cut-offs for treatment initiation. With few exceptions, once antiretroviral therapy has been initiated, this is lifelong although individual components of therapy may change over time [36]. Employment of HIV-infected HCWs Regulations and considerations In terms of managing HIV-infected HCWs, Department of Health guidance exists, with a similar document used in Scotland, and is also applicable to students in health care, the independent health care sector and volunteer HCWs [26,27]. Although many principles will be similar where infection with hepatitis B or C is present, these have not been considered here due to the narrower remit of this review. Within the UK, no reported HIV transmissions from HCWs to patients have occurred, with nine international reports involving four HCWs. However, global figures may be falsely low due to reporting bias [28,37]. Using a model based on transmission from an HCW to a patient in a single procedure following a single injury to the HCW, the risk of transmission from an HCW to a patient is estimated to be as low as between 1 in 42 000 and 1 in 420 000 [37,38]. Despite this, it has been considered necessary to protect patients with restriction of HIV-positive HCWs from performing EPPs [26,27,37]. However, the Department of Health and the devolved administrations launched a consultation exercise in December 2011, concerning a change to these recommendations, on the guidance of a tripartite group comprising the EAGA, the Advisory Group on Hepatitis and UKAP [28,39]. At the time of writing this review, the proposal remains at a consultation stage. The proposed change states that an HIV-infected HCW may be permitted to perform EPPs if they are established on combination antiretroviral therapy and have a consistently suppressed plasma viral load (<200 copies/ml on two consecutive plasma samples), prior to starting/resuming EPPs [28,39]. Viral load testing would occur every 3 months while performing EPPs, and significant rises above 200 copies/ml would preclude continuation of EPPs until it again drops to below this level. Patient notification exercises to cover the period of potential infectiousness may be required, and decisions regarding the need for this, as well as when EPPs may start, resume or cease would be made by a consultant in occupational medicine, informed by the relevant experts. The HCW would remain under joint supervision by this consultant and their HIV physician. Some HCWs may even opt to start antiretroviral therapy for occupational reasons, in C. McGOLDRICK: HIV AND EMPLOYMENT 245 order to be able to undertake EPPs, when such treatment would not necessarily be recommended otherwise [28]. Apart from EPPs, other circumstances exist where there is potential to transmit infection from an infected HCW, e.g. during physical assault by a patient where bleeding of both parties occurs [40]. In addition, infected HCWs should cover wounds, skin lesions and breaks in exposed skin with waterproof dressings/gloves [26,27]. For HIV-positive dentists, where undertaking EPPs is essential to their role and redeployment/retraining would be difficult, UKAP and the EAGA have previously granted permission to two positive dentists to provide dental care to HIV-infected patients, subject to conditions. These were that they remain under regular occupational health supervision, had clearance from the General Dental Council (GDC), and performed restricted procedures, and that patients gave informed consent to treatment by an HIV-positive dentist [37,41]. However, if the new proposed guidelines for HCWs with HIV do come into place, some of these restrictions would be removed [28]. At present, when there is uncertainty about whether an HCW can carry out EPPs, guidance may be obtained from UKAP [26,27,37]. UKAP have also provided advice on procedures pertaining to particular specialties and defined whether they consider them to constitute EPPs [26,27]. Their remit also involves provision of advice regarding the necessity of patient notification exercises when EPP has been carried out by an infected HCW [37]. Only patients who have undergone category 3 (high risk) EPPs, where there is a distinct risk of bleed-back, are traced, notified and offered testing, in order to prevent unnecessary anxiety from being imparted [37,39]. It is reassuring that although more than 30 patient notification exercises involving HIVpositive HCWs have occurred in the UK (1988–2008), with nearly 10 000 patients tested, no HIV transmissions have been reported, although not all patients agreed to testing, or could be contacted [28]. In exposure incidents where a risk of transmission to a patient has occurred, not necessarily in the context of an EPP, the HCW involved has a duty to cooperate fully with those conducting the risk assessment, providing all necessary information regarding their own infection status or risk behaviour [40]. Where the HCW’s HIV status is unknown, testing should be offered but cannot occur against their wishes, although EPPs can be restricted if refused [40]. If the test (and other b lood-borne virus (BBV) testing) proves negative, there is no need to inform the patient of the incident [40]. In comparison, the approach to infected HCWs in other countries can differ, with some (e.g. France and New Zealand) dealing with HIV-infected HCWs on a case-by-case basis. Some other countries have no policies, often because no infected HCWs have been notified in that country. Others (e.g. Australia) restrict infected HCWs from undertaking EPPs [28]. In the USA, independent regulations apply for each state, some completely restricting performance of invasive procedures (definition varies between states), while in others, consideration is made regarding the type of procedure, an HCW’s skill and technique, their ability to adhere to universal precautions, and their physical and mental state, before a final decision is made regarding restrictions. Such decisions tend thereafter to be subject to continual review and/or supervision of the HCW [42]. HIV testing of HCWs Since March 2007, policies concerning HIV testing of new UK National Health Service (NHS) HCWs [30,31], aiming to decrease risk of HIV transmission from staff to patients, have been in existence. New NHS HCWs are defined as people with direct clinical patient contact who are either new to the NHS, moving to (or training within) a post involving EPPs, or are returning to the NHS (dependent on activities engaged in while absent from the NHS). Students on placement, visiting fellows and volunteer HCWs who carry out EPPs are also included. Independent Health Care standards state that such HCWs comply with the Department of Health guidelines on HCWs infected with BBVs, and this extends to HIV testing. Providers of temporary staff to the NHS should also ensure that similar occupational checks are made [30,31]. As part of standard health clearance checks, all new HCWs should be offered HIV testing, although refusal or testing positive would not restrict employment unless the role involves EPPs. Where EPPs are involved, HIV testing is required, preferably early in the appointments/admissions process. Declining a test, or testing positive in this situation would mean EPP restriction, and if integral to the position/training would mean ineligibility for the position [30,31]. In all cases pre-test discussion should be carried out in a confidential environment, covering reasons for and benefits of testing, explaining whether it is mandatory or not for employment, and how the result will be given [43,44]. The HCW’s professional responsibilities in relation to HIV should also be discussed [30,31]. Regardless of new HCW HIV testing policies, all HCWs have ethical and legal duties to protect their patients. Therefore, if an HCW suspects that they may have been exposed to infection, even non-occupationally and irrespective of circumstance, prompt, confidential professional advice regarding whether testing is necessary must be sought. Failure to follow the advice would breach duty of care, a continual obligation for the HCW [26,27,45–48]. Such guidance is consistent with GMC, GDC and Nursing and Midwifery Council guidance, and extends to self-employed HCWs and health care students [26,27,45]. 246 OCCUPATIONAL MEDICINE Risks to the HIV-infected HCW Risks are to some extent dependent on the health of the HIV-infected HCW. Employment in a health care setting may place them at risk of acquiring infections from patients. This is particularly true for those exposed to individuals with active pulmonary tuberculosis and other infections that may be opportunistic in the immunocompromised, and should be a consideration when an occupational health physician advises on suitability for particular posts [26,27]. This is not always straightforward as HIV-infected HCWs may choose to work in infectious diseases or HIV services, which increases their risk of exposure to infections such as tuberculosis. An HIV-infected HCW may be prepared to accept the risk of acquiring opportunistic infections through work, but the consequent risks to patients must also be considered. HIV infection within the military Although many HIV-positive service personnel attend local non-military HIV services, designated military HIV medicine facilities are being further developed in the UK. This is to ensure that individuals receive specialized guidance from a military occupational viewpoint, so they can be best advised regarding the most suitable placements and roles within the military. Annual clinical reviews at these facilities are planned; concerned with the degree of limitation an individual’s HIV will have on their role if deployed. Routine follow-up by local non-military HIV services can however continue [49]. Despite the existence of such facilities for those who have already joined, HIV seropositivity/AIDS is listed among the many d iseases that can prevent enlisting within the British Army and the Royal Air Force, although the precise reasons for such restrictions are not provided [22,23]. Farther afield, the US Army has an extensive HIV screening protocol. If an American soldier is found to be infected with HIV, some restrictions apply, including no deployment/assignment overseas [50]. Airline pilots and air traffic control officers with HIV According to UK CAA guidelines [51], there exist restrictions to HIV-positive pilots and air traffic control officers in terms of classes of Joint Aviation Authorities certification that may be issued. Such restrictions exist to ensure that illness/medication does not affect work capability/ judgment. Deviation from such restrictions may occur for pilots, provided there are no symptoms/signs related to HIV or its therapy, and there is a low risk of disease progression/incapacitating events. However, there may be limitations imposed allowing infected individuals to fly only UK-registered aircraft. UK CAA guidelines detail the various assessments that are required of infected pilots and air traffic control officers, including HIV specialist, neurology and neuropsychological reviews. In addition, certificate holders are considered temporarily unfit to work during times of antiretroviral therapy initiation, modification or discontinuation. This can be reassessed after a 2-month period. In particular, where efavirenz is used, it is suggested that psychiatric and neurological examination may be needed. Regulations may change in 2012, when European Aviation Safety Agency rules are implemented [51]. In the USA, the Federal Aviation Administration’s protocol similarly stipulates the need for regular medical and cognitive function assessments for infected individuals [24]. Vaccination for employment purposes Vaccination may sometimes be required for employment purposes. Examples include hepatitis B vaccination for HCWs, as well as travel vaccines for employees who travel to certain countries as part of their work. While hepatitis B immunization can be administered at any CD4 count, it may fail to produce an adequate immune response if administered when the CD4 count is low. Measurement of hepatitis B surface antibody 6–8 weeks after final vaccine dose is recommended. If <10 IU/l, three further double-doses of vaccine should be offered at monthly intervals. One further vaccine dose should be offered if the level is between 10 and 100 IU/l [52]. Travel vaccination may be affected by HIV status when considering yellow fever vaccination. As it is a live vaccine, administration is contraindicated if CD4 counts are lower than 200 cells/µl and should only be offered at higher counts after a discussion concerning the risks and the benefits. An exemption certificate should be given if international travel requirements rather than true exposure risk are the only reasons to vaccinate. In addition, administration to HIV-positive individuals aged over 60 is not advised. This is until there are more available data concerning neurotropic and viscerotropic disease, which are potential complications that are of higher incidence in older recipients. If given, it should be administered at least 2 weeks before travel, and the recipients should be monitored closely. If it cannot be/is not given, it is preferable not to deploy the person to a yellow fever risk area [52]. More vaccination information is available within the ‘British HIV Association guidelines for immunization of HIV-infected adults 2008’ [52]. International work-related travel Some countries have restrictions preventing HIVpositive foreign nationals from entering their country. Therefore, some international work-related travel may C. McGOLDRICK: HIV AND EMPLOYMENT 247 be affected, and international travel proved difficult for 27% of respondents in one survey [9]. Many countries, including Saudi Arabia, United Arab Emirates, Russia and Singapore, continue to restrict entry of HIV-infected individuals, although similar restrictions enforced by the USA were lifted on 4 January 2010. Some countries may have waivers for certain situations [53]. It would be discriminatory under the Equality Act 2010 to deny career progression/employment because of inability to travel to certain destinations, unless it can be clearly justified why such a policy is essential for an employee’s role or for the company [34]. occupational environments. Examples are shown in Box 2 [40,55]. Employers’ responsibilities Employers have legal duties to protect staff under the Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999. In addition, under the Control of Substances Hazardous to Health Regulations 2002, there is a legal duty to assess risk of infection for employees, implementing suitable precautions [55]. Previous occupational transmissions Occupational and other exposures to HIV infection Percutaneous and mucocutaneous exposure Needlestick injuries are percutaneous injuries from needles/other sharp materials, which may be contaminated by blood/body fluids [54]. If materials become contaminated with such fluid, decontamination processes should be used as per local policies [55]. Apart from blood, fluids that may pose a risk of HIV transmission include amniotic fluid, cerebrospinal fluid, exudative/other fluid from burns/skin lesions, breast milk, pericardial fluid, peritoneal fluid, pleural fluid, saliva associated with dentistry, semen, synovial fluid, unfixed human tissues and organs, vaginal secretions or any other blood-stained fluid [40,54]. HIV may also be transmitted through mucocutaneous exposure to such materials through contamination of non-intact skin, or potentially via human bites if the skin becomes broken [40,54]. There has also been a documented HIV seroconversion in a police officer resulting from hand wounds sustained after punching a man in the teeth during a bloody arrest [56]. Although needlestick injuries occur frequently within civilian health care settings, they may also occur in other Although universal precautions are advocated in health care environments, and similar precautions in other work environments [27,54,55], five documented cases of HIV seroconversions among UK HCWs after specific exposure incidents have occurred (data published in 2008). Another 23 were possibly occupationally acquired, although 21 were probably contracted in countries of high HIV prevalence, e.g. within Africa or the Indian subcontinent [57,58]. Notably, of all UK exposures to HIV-infected sources reported from 2005 to 2007, infection in the source was unknown at the time of the incident in 13% (41/316), highlighting the importance of universal precaution adherence [58]. Precautions in various work environments There are various other examples of precautions that may be taken to reduce the risk of such injuries within many different occupational environments. For example, within the waste and recycling industry, good practice would be to provide gloves with a high degree of puncture resistance (but these must not be relied upon), puncture-resistant clothing, sharps boxes, other sharp resistant containers (e.g. wheelie bins) and tools to pick up needles (e.g. pincers) and to promote Box 2. Occupational environments with potential HIV exposure risks Civilian/other health care settings Police force Fire service Rescue services Custodial services Voluntary aid agencies Social services Armed forces Laboratories Needle exchange services Tattooing and piercing services Sewage processing Embalming and crematorium work Mortuaries Local authority services (e.g. street cleaning, public lavatory maintenance, refuse disposal) Medical/dental equipment repair & decontamination Beauticians Hairdressing Plumbing Vehicle recovery and repair Contact sports 248 OCCUPATIONAL MEDICINE sweeping needles with dustpans and brushes to aid disposal [59]. For sewage workers who may potentially be percutaneously or mucocutaneously exposed (e.g. water containing sanitary towels, condoms), risks are minimized due to HIV’s extreme dilution and poor survival in sewage (up to 12 h in non-chlorinated sewage) [60,61]. In respect of mortuary services, measures to minimize the risk of HIV transmission are also necessary. Examples include wearing visors where there is a splash risk at post-mortems. Where HIV is present, embalming should also be avoided. This is because there is a potential risk of contact with blood when it is replaced with a preservative solution using injection equipment. In addition, body bags should be used if there is a known risk of HIV [62]. The UK Ministry of Defence Safety Handbook also includes precautions to reduce occupational risk of BBV acquisition for armed forces members. Although mainly geared towards those within military health care environments, it also highlights the risk of HIV transmission from blood transfusion for all military members, particularly in countries of high HIV prevalence. It suggests ways to minimize the risk of being transfused with contaminated blood and emphasizes the importance of carrying first-aid kits with sterile medical equipment [63]. Similarly, within the prison service, where inmate HIV prevalence is higher than in the general population, there exists a best practice framework, covering what to do in incidents of potential exposure [64]. In terms of the police force, a working group in Scotland considered whether an assailant of a police officer should be subjected to mandatory HIV testing. However, this was not advised, as at the time of testing, the person would not yet have been convicted. By the time a conviction occurred, this would represent too long a delay for testing to be beneficial, as at that stage HIV post-exposure prophylaxis (PEP) initiation (see later) would no longer be effective [65]. In Scotland, data were collected over a period of 47–55 weeks in police forces and in the Scottish Prison Service. One hundred and eight exposure incidents were reported, although most (74%) were from spits, bites or splashes. Just over half were deliberate, and 84% occurred outside occupational health working hours [66]. There may also be HIV exposure risks within professional/semi-professional sport, due to potential contact with blood from an infected person. The risk is higher with contact and collision sports. The US Centers for Disease Control say that with the exception of boxing, overall the risk is low at less than one potential transmission in 1 million games, although estimated risks reported by others vary widely. The International Federation of Associated Wrestling Styles and the International Boxing Federation say that HIV testing is compulsory for participants in their sports. Despite this, there have been no definite reported transmissions in sport, with one possible exception in a footballer from Italy, where occupational transmission could not be ruled out. Preventative measures that can be taken include providing prompt and appropriate treatment for bleeding injuries, using appropriate protective equipment such as mouth protectors, covering wounds with occlusive dressings and removing/cleaning contaminated equipment from activity areas. In general, the decision to compete should be personal to the individual with HIV. Other HIV risks that may be encountered within sport include the sharing of needles, e.g. for steroids, hormones and vitamins [67]. For teachers, there may be risks through blood spillage, bites or scratches from pupils, and guidelines are available for such situations. The risks may be higher for those working with pupils with special educational needs. An additional risk may be posed if a teacher comes across a discarded needle left by a trespasser [61,68]. Another setting where there may be risk is that of workers who deal with vehicles that are involved in road traffic accidents. The hard and soft surfaces of damaged motor vehicles may become contaminated following such incidents, although no documented HIV transmission has ever occurred in a worker dealing with such an incident [61]. When there has been a potential exposure In the event of a percutaneous injury, washing with soap/ water, avoiding antiseptics/skin washes and encouraging bleeding are advised, while exposed mucous membranes should be irrigated copiously with water including before and after contact lens removal [40,54]. While the risk of HIV transmission is small, these injuries can prove worrying for the workers concerned, and therefore appropriate counselling is required [40,54]. The approximate average risks of HIV transmission following some exposures to HIV-infected blood are shown in Table 1 [40,58]. However, factors that increase risk should be considered (Box 3)[40,57,58,69]. Encouragement should also be given to provide blood at baseline for storage, which may be analysed later if subsequent tests detect HIV infection [40]. Employment and risks of sexual transmission Sexual transmission of HIV may also be relevant in the occupational health setting, considering that international Table 1. Average risk to a health care worker of contracting HIV from an HIV-positive source Type of exposure Estimated average risk of transmission (%) Percutaneous Mucocutaneous Intact skin 0.3 <0.1 No risk C. McGOLDRICK: HIV AND EMPLOYMENT 249 Box 3. Factors which may increase risk of HIV transmission after percutaneous injury Deep injury Hollow-bore needle Visible blood on injurious device Device had been placed in source’s artery/vein Terminal/late stage HIV-related illness of source High viral load of source (during seroconversion, during later stages of infection) travel features in some lines of work, e.g. the oil and gas industry, armed forces and business travel. This may involve travel to regions of high HIV prevalence where there are even greater risks from casual sexual encounters than in the UK [70]. For example, much of the largescale oil and gas sector project activity occurs in less developed countries where HIV is often of much higher prevalence than in the UK. Such regions include West Africa (e.g. Nigeria, Angola, Ghana and Cameroon) and Asia (e.g. India, China, South-East Asia and East Russia) [71]. It is recognized that many field-based workers are at risk of HIV through sexual networking with commercial sex workers and settlers at oil locations. This is perhaps compounded by spending long periods away from their usual sexual partners [71,72]. A pre-travel safer sex message to such workers is therefore important [70]. Post-exposure prophylaxis Background The need for PEP using antiretroviral drugs should be considered where there has been a significant risk of HIV exposure. EAGA guidance in this matter (briefly summarized) can be used in both health care and non-health care settings [40]. As antiretrovirals are not licensed for this particular purpose, the recipient should be advised of its off-label use, despite national UK guidelines recommending its provision [40,58]. Although zidovudine monotherapy has been the only PEP regimen studied, combination therapy with three drugs has been the consensus UK recommendation since 1997, extrapolated from its greater efficacy when used in HIV treatment [40]. This contrasts with guidance from the USA that suggests that either two- or three-drug PEP regimens may be used depending on the assessed level of risk of transmission from the incident [73]. But how does PEP work? As animal models show viral dissemination after primary HIV infection does not occur immediately, theoretically, there is a window where PEP may prevent infection from becoming established [40]. Due to ethical considerations, no randomized controlled trials of its use have been performed, and the recipient should be informed of its unproven efficacy. Its recommendation is therefore based on limited evidence from fairly weak studies. An example includes a case–control study conducted in the pre-HAART era on HCWs with occupational percutaneous exposure to HIV-infected blood. Those who seroconverted (33 individuals) were significantly less likely than those who did not (665 individuals), to have taken post-exposure zidovudine monotherapy (OR = 0.19; 95% CI = 0.06–0.52) [57,69]. If indicated, PEP should be given as soon as possible (ideally within 1 h), earlier use being more effective. However, it may be initiated up to 72 h later and is recommended for 28 days [40,58]. Not all HIV-exposed HCWs can tolerate a full 28-day course of PEP, although tolerability has improved with the use of more modern antiretrovirals. Protease inhibitors are particularly hard to tolerate. However, every dose of PEP is likely to reduce the risk. In occupational settings outside of the health care environment, accident & emergency departments or sexual health clinics would ordinarily provide the worker with PEP or guide them to the appropriate place [55]. Ordinarily, the need for PEP’s continuation would be decided in conjunction with a physician experienced in HIV management, and any concerns regarding initiation should be discussed with such a physician. UK surveillance data show that early initiation is achievable, PEP being received within 1 h in 37% (22/59) of HCWs exposed to an HIV-positive source and within 24 h in 89% (53/59) [58]. In the UK (2000–07), 889 HCWs were occupationally exposed to HIV infection, of which 700 (79%) initiated PEP [58]. There appear to be no similar statistics published for occupational exposures in non-health care environments. When PEP should be considered PEP should not be offered for exposures to low-risk materials such as urine, vomit, faeces or saliva (unless blood stained or associated with dentistry), irrespective of source HIV status. For high-risk materials, urgent preliminary risk assessment should inform whether PEP is indicated. It is generally offered when the source is already known to be HIV positive or is considered at high risk of infection. However, some potentially positive source patients may not disclose or be aware of their risk. Where the source is unknown, e.g. injury from a discarded needle, judgement based on epidemiological likelihood of source HIV in that setting is necessary. PEP is unlikely to be justified in the majority of exposures [40]. Antiretrovirals used The recommended PEP starter pack regimen in the UK consists of tenofovir, emtricitabine, and lopinavir with ritonavir boosting, although local variations are 250 OCCUPATIONAL MEDICINE acceptable [40]. Boosting refers to the pharmacokinetic action of low-dose ritonavir (a protease inhibitor without antiretroviral action at such doses), as a potent inhibitor of cytochrome P450 3A4, used to boost lopinavir serum concentration by inhibiting its metabolism [6]. Although this regimen may be continued for the treatment period, it may be modified by an HIV physician if source drug resistance is known/suspected/discovered. However, this must not delay standard regimen initiation. Vigilance for adverse effects is also necessary [40]. HIV testing after exposure incidents Post-exposure testing, like all HIV testing, should be with fourth-generation combined antibody and antigen assays. Testing for HIV RNA is not advised due to the high falsepositive rate. Testing should occur at least 12 weeks after the incident or at least 12 weeks after PEP completion, if given [40,44]. Where the person is already immunocompromised, develops an illness compatible with seroconversion or the source is co-infected with viral hepatitis, follow-up may need to be longer [40,58]. During the follow-up, modification of working practice is not necessary for HCWs performing EPPs, unless seroconversion is confirmed [40]. Practising safer sex and avoiding blood donation during the follow-up should nevertheless be discussed [40,54]. If, through testing, a worker is found to have acquired HIV, they should be referred to a physician involved in HIV management [54]. Financial help In terms of financial help for individuals who contract HIV by occupational means, there may be eligibility under the Industrial Injuries Disablement Benefit Scheme if a level of disablement has been established [27,40,54,74]. For HCWs, compensation may be available through the NHS Injury Benefits Scheme or the Northern Ireland Health and Personal Social Services Injury Benefits Scheme if there is reduced earning ability as a result of occupationally acquired infection [27,75]. Ill-health retirement benefits under the NHS Pension Scheme may be payable when permanent incapacity in performing duties occurs because of infection [27]. In other situations where transmission has not necessarily occurred through the course of employment but affects the ability to work, other sources of financial s upport may be available, e.g. the British Dental Association benevolent fund for dentists [76]. Conclusions HIV-positive individuals enjoy working within a variety of occupational roles and are legally protected from workplace discrimination by the Equality Act 2010. Indeed, occupational disclosure of HIV status should be treated confidentially. Some workplace accommodations may be considered, including time off for clinic attendances, although often HIV status does not interfere greatly with work. For the particular circumstance of HIV-infected HCWs, for patient protection reasons, involvement in EPPs is currently restricted, but the regulations concerning this are likely to change soon. In addition, there is now a policy to offer HIV testing to all new HCWs, with this being mandatory for those involved in EPPs. In addition, there are also some employment restrictions within the military and aeronautical industries. Other issues relating to employment that may need to be considered include those of work-related vaccination of HIV-positive employees and some international travel restrictions that prevent travel to some countries. Prevention of HIV transmission to the worker in various working environments is another consideration, and PEP may be indicated after a potential HIV exposure. 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Speakers include Professor Tom Kirkwood (Newcastle University) Professor Sir John Burn (Newcastle University) Professor Simon Folkard (University of Swansea) Professor Paul Cullinan (Imperial College London) Dr Lesley Rushton OBE (Imperial College London) Professor Graham Devereux (University of Aberdeen) Key topics are •• Ageing and Work •• Shiftwork •• Future Developments in Occupational Health •• Clinical Updates More information is available at http://www.somasm.org.uk/index.asp